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--T-Ues z/-ao I0 /0:30l - C-00 — <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> Vfscqnsln ( POwTS) Property Address:a SS�Z <br /> Department of Commerce INSPECTION REPORT <br /> So"and auiidhW Dwision (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 53.2.269 Cry <br /> Pa nal information you pnmde my be used for Seton Privacy Law,s. 15.04(1 m 5a 10-cp <br /> Permit Holders Nam - City Vit a Town of: State Plan Transaction IDM: <br /> �hn r(��s-6� a <br /> CST BM Elev: Imp BM Eley. BM Description: Parcel Tax No: <br /> JW100 1AdOgk I o` _ QRG- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Cr& Benchmark /, -/6/43 10a co <br /> Dosing <br /> Aeration Bldg.Sewer 7 3Z <br /> Holding St I Ht Inlet 71 00 9 <br /> TANK SETBACK INFORMATION StkHtOutlet & 9517 <br /> TANK TO PIL WELL BLDG V TTOO ROAD Dt Inlet <br /> Septic >zo >70' (o' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist Pipe <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> surface � 83 93•� <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Folcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width '311 Length qj ' No of Cells 1 Type of System Manufacttuuurrer: <br /> SETBACKLEACHING / <br /> P I L Bldg wea OHWM of Naw �riMEbts] CHAMBER '� �w <br /> INFORMATION waters /n ( Model Number <br /> CELLTO /0 6flG!) "/G' >Bp Ni^ li_—x <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia_ Spac Spacing UrYes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> Permit Posted?OY N <br /> Schedule 40 Vents and Observation Pipes?OT) N <br /> Cover Material: <br /> Effluent Filter Manufacturer 15y6T Model <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 20 � /D 1 7 b <br /> Use other side for additional information Data POWiS 1 or's Signature Cert No <br />